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GOVERNMENT OF INDIA, MINISTRY OF EXTERNAL AFFAIRS

PASSPORT APPLICATION FORM

Please read the Passport Instruction Booklet carefully before filling the form. Fill this form in CAPITAL LETTERS using
blue/black ink ball point pen only. Furnishing of incorrect information/ suppression of information would lead to rejection of the
application and would attract penal provisions as prescribed under the Passports Act, 1967. Please produce your original
documents at the time of submission of the form.

Service Required
Application Reference Number

16-0005506514

Applying For

FRESH

Type of Application

TATKAAL

Type of Passport Booklet

NORMAL

Applicant Details
Applicant's Name

VANSHITA

Date of Birth (DD/MM/YYYY)

07/02/2006

Validity Required

NA

Place of Birth (Village/Town/City)

PATTI

District

TARN TARAN

State/UT

PUNJAB

Country

INDIA

Gender

FEMALE

Marital Status

SINGLE

Citizenship of India by

BIRTH

Employment Type

STUDENT

Is either of your parent (in case of

minor)/spouse, a government servant?

Educational Qualification

BETWEEN 6TH AND 9TH STANDARD

Are you eligible for Non-ECR category?

Visible Distinguishing Mark

NO

Aadhaar Number

461625717158

Signature/Left Hand Thumb Impression

of Illiterate Applicant and Minors who
cannot sign.

Family Details

1 of 3

Father's Name

RAMESH KUMAR

Mother's Name

NAGINA RANI

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Present Residential Address Details

Residing Since(MM/YYYY)

02/2006

Address

675/9 NEAR KATLUI MANDIR WARD NO -9, PATTI, PATTI,

TARN TARAN, PUNJAB

PIN

143401

Mobile/Tel No.

9914641222

E-mail

HANDAAMRITSAR@GMAIL.COM

First Reference Name And Address

LALIT KUMAR NEAR KATLUI MANDIR WARD NO-9 , PATTI

Mobile/Tel No.

7837374040

Second Reference Name And Address

RAJINDER KUMAR NEAR KATLUI MANDIR WARD NO -9

PATTI

Mobile/Tel No.

9814795858

Permanent Residential Address

Address

675/9 NEAR KATLUI MANDIR WARD NO -9, PATTI, PATTI,

TARN TARAN, PUNJAB

PIN

143401

Mobile/Tel No.

9914641222

Emergency Contact Details

Name and Address

RAMESH KUMAR

Mobile/Tel No.

9914641222

Fee Details (Not to be filled by applicants submitting the application at Passport Seva Kendra/Passport Office)
Fee amount in (Rs)
If paid by Demand Draft(DD), provide the following details
DD Issue Date (dd/mm/yyyy)
DD Expiry Date (dd/mm/yyyy)
Bank Name
Branch

Enclosures
1.

6.

2.

7.

3.

8.

4.

9.

5.

10.

Self Declaration
I owe allegiance to the sovereignty, unity and integrity of India, and have not voluntarily acquired citizenship or travel document of
any other country. I have not lost, surrendered or been deprived of the citizenship of India and I affirm that the information given by
me in this form and the enclosures is true and I am solely responsible for its accuracy, and I am liable to be penalized or
prosecuted if found otherwise. I am aware that under the Passports Act, 1967 it is a criminal offence to furnish any false information

2 of 3

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or to suppress any material information with a view to obtaining passport or travel document.

3 of 3

Place

AMRITSAR

Date

05/05/2016

Signature/Left Hand Thumb Impression of

Applicant (If applicant is minor, either parent
to sign)

05/05/2016 07:29 PM